NCCN Categories of Evidence and Consensus
Category 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise noted.
Clinical trials: NCCN believes that the best management for any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Healthy Lifestyles
Healthy lifestyle habits, such as engaging in routine physical activity, maintaining a healthy diet and weight, and avoiding tobacco use, have been associated with improved health outcomes and quality of life. For some cancers, a healthy lifestyle has been associated with a reduced risk of recurrence and death.1-6 Therefore, survivors should be encouraged to achieve and maintain a healthy lifestyle, including attention to weight management, physical activity, and dietary habits. Survivors should be advised to limit alcohol intake and avoid tobacco products, with emphasis on tobacco cessation if the survivor is a current smoker or user of smokeless tobacco. Clinicians should also advise survivors to practice sun safety habits as appropriate, such as using a broad-spectrum sunscreen, avoiding peak sun hours, and using physical barriers. Finally, survivors should be encouraged to see a primary care physician regularly and adhere to age-appropriate health screenings, preventive measures (eg, immunizations), and cancer screening recommendations.
The NCCN Panel made specific recommendations regarding physical activity, weight management, nutrition, and supplement use, which are discussed herein. Although achieving all of these healthy lifestyle goals may be difficult for many survivors, even small reductions in weight among overweight or obese survivors or small increases in physical activity among sedentary individuals are thought to yield meaningful improvements in cancer-specific outcomes and overall health.7
Physical Activity
During cancer treatment, many survivors become deconditioned and can develop impaired cardiovascular fitness because of the direct and secondary effects of therapy.8 Randomized trials have shown that exercise training is safe, tolerable, and effective for most survivors. Structured aerobic and resistance training programs after treatment can improve cardiovascular fitness and strength and can have positive effects on balance, body composition, and quality of life.9-17 The effectiveness of exercise training is especially well studied in women with early-stage breast cancer. Survivors of breast cancer who exercise have improved cardiovascular fitness and therefore an increased capacity to perform daily life functions, resulting in a better quality of life.16-20
NCCN Clinical Practice Guidelines in Oncology: Survivorship: Healthy Lifestyles, Version 2.2014
Version 2.2014, 07-22-14 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 9; 10.6004/jnccn.2014.0121
NCCN Clinical Practice Guidelines in Oncology: Survivorship: Healthy Lifestyles, Version 2.2014
Version 2.2014, 07-22-14 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 9; 10.6004/jnccn.2014.0121
NCCN Clinical Practice Guidelines in Oncology: Survivorship: Healthy Lifestyles, Version 2.2014
Version 2.2014, 07-22-14 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 9; 10.6004/jnccn.2014.0121
NCCN Clinical Practice Guidelines in Oncology: Survivorship: Healthy Lifestyles, Version 2.2014
Version 2.2014, 07-22-14 ©2014 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN®.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 9; 10.6004/jnccn.2014.0121
In addition, observational studies have consistently found that physical activity is linked to decreased cancer incidence and recurrence, and increased survival for certain tumor types.13,21-29 For example, one meta-analysis of 6 studies including more than 12,000 survivors of breast cancer found that postdiagnosis physical activity reduced all-cause mortality by 41% (P<.00001) and disease recurrence by 24% (P=.00001).23 Data from other meta-analyses primarily consisting of observational studies of survivors of colorectal, ovarian, non-small cell lung, brain, prostate, and breast cancers show that physical activity is associated with both decreased all-cause mortality and/or cancer-specific mortality.21,24,28,30 In fact, analyses of data from 986 survivors of breast cancer from the National Runners’ and Walkers’ Health Studies found that mortality decreased with increased rates of energy expenditure.29 Evidence in other disease sites is less robust, but also suggests survival benefits associated with exercise in survivors after treatment.30
Data also support the idea that inactivity/sedentary behavior is a risk factor for cancer incidence and mortality, and impacts mood and quality of life in survivors, independent of the level of an individual’s recreational or occupational physical activity.1,31,32 For example, in a cohort of more than 2000 survivors of nonmetastatic colorectal cancer, those who spent more leisure time sitting had a higher mortality than those who spent more time in recreational activity.1
Evaluation and Assessment for Physical Activity: Survivors should be asked about readiness for participation and their current level of physical activity at regular intervals. The Godin Leisure-Time Exercise Questionnaire is one tool that can be used to assess a survivor’s exercise behavior, with a modified version also able to assess daily time in moderate-to-vigorous activity.33,34
For survivors who are not meeting the guideline recommendations (see later discussion), barriers to physical activity should be discussed and addressed, if possible. Common barriers include not having enough time to exercise, not having access to an acceptable exercise environment, uncertainty about safety of exercise posttreatment, lack of knowledge regarding appropriate activities, and physical limitations.35 In addition, alleviation of pain, fatigue, distress, or nutritional deficits can facilitate the initiation of an exercise program.
Risk Assessment for Exercise-Induced Adverse Events: Exercise is considered safe for most survivors.16,17,36 However, a significant portion of survivors may have comorbid conditions or risk factors that make them unable to safely exercise without trained supervision.37 Therefore, a risk assessment is required for all survivors before prescribing a specific exercise program.16,38 The type of cancer, treatment modalities received, and the number and severity of comorbidities determine risk levels.36 Thus, disease and treatment history, late and long-term effects, and comorbidities should be assessed. Exercise is typically contraindicated in survivors immediately (≈30 days) after surgery (except for supervised physical activity with early mobilization and referral to a trained therapist) and in those with severe anemia, a worsening condition, or active infection.16,38 A standardized preparticipation screening questionnaire, such as the The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+),39 can also be considered to identify patients for whom unsupervised physical activity is likely safe versus those for whom it may pose undue risk.
Survivors with myeloma, peripheral neuropathy, bone metastases, poor bone health, arthritis, or musculoskeletal issues are considered at moderate risk for exercise-induced adverse events. Stability, balance, and gait should be assessed in survivors with peripheral neuropathy before they engage in exercise, and exercise choice should be made based on the results (ie, stationary bike or water aerobics for survivors with poor balance). Survivors with osteoporosis, myeloma, or bone metastases should have fracture risk and/or bone density assessed as clinically indicated before initiating an exercise program. Moderate-risk survivors can often follow the general recommendations for physical activity; however, medical clearance and/or referrals to trained personnel, such as a physical therapist, certified trainer, cancer rehabilitation specialist, pulmonary or cardiac rehabilitation specialist, or exercise specialist, can also be considered. Specialized training in cancer exercise is available through the American College of Sports Medicine (ACSM; http://www.acsm.org/get-certified). Survivors should be encouraged to use an ACSM-certified trainer when available.
Survivors at high-risk for exercise-associated adverse events include those with a history of lung surgery or major abdominal surgery, an ostomy, cardiopulmonary comorbidities (eg, chronic obstructive pulmonary disease, chronic heart failure, coronary artery disease cardiomyopathy), ataxia, severe nutritional deficiencies, or extreme fatigue. These survivors should receive medical clearance and referral to trained personnel for a supervised exercise program.36 In general, exercise should be individualized to the participant based on current exercise level and medical factors, and should be progressed in terms of intensity, duration, and frequency as tolerated.
Survivors with lymphedema are considered at moderate risk if they are performing resistance/strength-training exercise of the affected limb, but at low risk if they are participating in cardiovascular/aerobic exercise or strength training of unaffected limbs.40-45 Resistance training in survivors with or at risk for lymphedema is discussed in more detail in the section “Resistance and Strength Training,” opposite column.
Physical Activity Recommendations for Survivors: Both the American Cancer Society and the ACSM have made physical activity recommendations for cancer survivors.15,16 The panel supports these recommendations and has adapted them as follows:
All survivors should be encouraged to avoid inactivity or a sedentary lifestyle and return to daily activities as soon as possible.
Survivors who are able should be encouraged to engage in daily physical activity, including exercise, routine activities, and recreational activities.
Physical activity and exercise recommendations should be tailored to individual survivors’ abilities and preferences.
General recommendations for cancer survivors:
○ Overall volume of weekly activity should be at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity, or an equivalent combination
○ Individuals should engage in 2 to 3 sessions per week of strength training (see next section on “Resistance and Strength Training”) that includes major muscle groups
○ Major muscle groups should be stretched on the days exercises are performed.
The panel acknowledges that most survivors do not meet these exercise recommendations, and a significant portion report that they perform no leisure-time activity.46,47 However, the evidence suggests that even light-intensity physical activity can improve physical functioning in survivors.48 For survivors who are inactive, clinicians must not advise the immediate initiation of a high-intensity, high-frequency program.49 Instead, the panel suggests that clinicians provide sufficient information to encourage survivors to avoid inactivity.38 The panel recommends starting inactive survivors with 1 to 3 light/moderate-intensity sessions of 20 minutes or more per week, with progression based on tolerance, as outlined in the guidelines.49 For survivors tolerating the minimum guideline recommendations, clinicians should consider encouraging variation within the exercise program or increasing the amount of time engaged in physical activities/exercise modalities. Walking and using a stationary bike are safe for virtually all survivors.
Resistance and Strength Training: The health benefits of resistance training include improvement in muscle strength and endurance, improvements in functional status, and maintenance/improvement in bone density. Studies in survivors have shown improvements in lean body mass, muscular function, and upper body strength.50-53 A recent systematic review of 15 studies of resistance training interventions during and/or after cancer treatment concluded that meaningful improvements in physiologic and quality-of-life outcomes can be achieved.51 A similar review of 11 randomized controlled trials came to similar conclusions.53
Multijoint exercises (eg, chest press, shoulder press, squats, lunges, pushups) are recommended over exercises focused on a single joint, and all major muscle groups (chest, shoulders, arms, back, abdomen, and legs) should be incorporated into a resistance training program. For survivors who do not currently engage in resistance training, clinicians should recommend that they start with 1 set of each exercise and progress up to 2 to 3 sets as tolerated. A weight that would allow the performance of 10 to 15 repetitions is recommended; however, individualizing recommendations for resistance and strength training is important.
Strength training has been shown to be safe for survivors at risk for or with lymphedema, and may even improve lymphedema symptoms.40-44 Still, caution is advised in this population,45 and referral to a lymphedema specialist for evaluation before starting a physical activity program that involves strength or resistance training of the affected limb should be considered. The panel lists special considerations for strength training in this population of survivors in the guidelines, including the use of compression garments, working with a professional trainer, slow progression as tolerated, and baseline and periodic evaluation of lymphedema. The National Lymphedema Network has published a position statement with additional guidance for exercise in individuals with lymphedema.54
Interventions to Increase Physical Activity: Dozens of studies have looked at the efficacy of a variety of behavioral interventions for increasing exercise behavior in cancer survivors.16 However, data comparing different interventions are limited, and there is currently no “best” physical activity program for cancer survivors.55-58 Several studies have examined the physical activity and counseling preferences of survivors, with the goal of informing possible strategies to best encourage increased activity in this population.59-61
The panel suggests several strategies to help increase physical activity. These strategies include a simple recommendation from a physician, physical therapist, and/or certified exercise physiologist.62-64 In addition, participation in supervised exercise programs or classes or use of a pedometer may be helpful for survivors.65-68 Print materials, telephone counseling, motivational counseling, and theory-based behavioral approaches (discussed in the next section) are other strategies that may be effective for increasing physical activity in the survivor population.66,68-72
Health Behavioral Change
Lifestyle behaviors are one area cancer survivors can control if they are encouraged to change and are aware of resources to help them. Ambivalence about changing behavior is common in the general population, but among cancer survivors levels of motivation are often heightened, especially close to the time of diagnosis.10,62,73
Some data suggest that recommendations from the oncologist can carry significant weight for patients with cancer, yet many providers do not discuss healthy lifestyle changes with survivors.62-64 Print materials and telephone counseling are other strategies that may be effective for improving healthy behavior in the survivor population, and several trials show support for these strategies.66,68,71,72 In fact, a recent trial showed that telephone-based health behavior coaching had a positive effect on physical activity, diet, and body mass index in survivors of colorectal cancer.71 Moreover, results of the recently completed Reach Out to Enhance Wellness (RENEW) trial showed that an intervention of telephone counseling and mailed materials in 641 older, obese, and overweight survivors of breast, prostate, and colorectal cancers not only resulted in improved diet quality, weight loss, and physical activity but also had a long-lasting effect that was sustained a year after the intervention was complete.
Another strategy, motivational counseling, may be an effective technique for increasing physical activity and other healthy behaviors in cancer survivors.69,70 Motivational counseling focuses on exploring the survivor’s thoughts, wants, and feelings and is directed at moving through ambivalence so survivors choose to change their behavior.74 Other behavioral strategies may also be useful, such as improving self-efficacy (ie, the belief that one can perform the actions of new activity and maintain this practice by addressing barriers and planning for behavior change) and self-monitoring.75,76
Individual Disclosures for the NCCN Survivorship Panel
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